Provider Demographics
NPI:1710942917
Name:MUSUNURU, SANDEEPA (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDEEPA
Middle Name:
Last Name:MUSUNURU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 W MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-6800
Mailing Address - Country:US
Mailing Address - Phone:432-697-1061
Mailing Address - Fax:432-697-7089
Practice Address - Street 1:2405 W MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6800
Practice Address - Country:US
Practice Address - Phone:432-697-1061
Practice Address - Fax:432-697-7089
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0260208600000X, 2086S0127X, 208600000X
NC2010-01119208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CW789OtherBLUE CROSS
TXTXB140254OtherMEDICARE
TX286298901Medicaid